ABA Through Insurance Intake Form

ABA Through Insurance Intake Form
Date*

MonthDayYear
Date
Parent Name*
Address*

Street Address Line 2

City / Zip CodeState / Province

Postal / Zip Code
Email*
example@example.com
Telephone*
Child Name*
DOB*
Insurance*
Member ID*
Policy Holder name & DOB *
Does your child have an Autism diagnosis?*

YesNo
AVAILABILITY FOR THERAPY (SCHEDULE)*
Are you interested in our in house ABA Clinic in Farmingdale or Port Jefferson?*

Port JeffersonFarmingdaleHome
*Can commit to 8 hours or more of ABA therapy per week? Yes or No
Are you looking to enroll your child (2-5 year old) in the private insurance program?

YesNo
How did you hear about us?*

Social MediaSearch EngineInsurance DirectoryDoctor's OfficeLaw FirmSchool District Office/SchoolThrough Current Services/Service ProvidersAgency Marketing EmailsWord of MouthOther
Please upload picture of front and back of your insurance card

Cancelof
Should be Empty: